Pregnancy outcomes of Taiwanese women with gestational diabetes mellitus: a comparison of Carpenter-Coustan and National Diabetes Data Group criteria

Gestational diabetes mellitus and adverse maternal and perinatal outcomes in twin and singleton pregnancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the risk of adverse maternal and perinatal complications between twin and singleton pregnancies affected by gestational diabetes mellitus and the respective group without gestational diabetes mellitus (controls).

DATA SOURCES

A literature search was performed using MEDLINE, Embase, and Cochrane from January 1980 to May 2023.

STUDY ELIGIBILITY CRITERIA

Observational studies reporting maternal and perinatal outcomes in singleton and/or twin pregnancies with gestational diabetes mellitus vs controls were included.

METHODS

This was a systematic review and meta-analysis. Pooled estimate risk ratios with 95% confidence intervals were generated to determine the likelihood of adverse pregnancy outcomes between twin and singleton pregnancies with and without gestational diabetes mellitus. Heterogeneity among studies was evaluated in the model and expressed using the I2 statistic. A P value of <.05 was considered statistically significant. The meta-analyses were performed using Review Manager (RevMan Web). Version 5.4. The Cochrane Collaboration, 2020. Meta-regression was used to compare relative risks between singleton and twin pregnancies. The addition of multiple covariates into the models was used to address the lack of adjustments.

RESULTS

Overall, 85 studies in singleton pregnancies and 27 in twin pregnancies were included. In singleton pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.85; 95% confidence interval, 1.69-2.01), induction of labor (relative risk, 1.36; 95% confidence interval, 1.05-1.77), cesarean delivery (relative risk, 1.31; 95% confidence interval, 1.24-1.38), large-for-gestational-age neonate (relative risk, 1.61; 95% confidence interval, 1.46-1.77), preterm birth (relative risk, 1.36; 95% confidence interval, 1.27-1.46), and admission to the neonatal intensive care unit (relative risk, 1.43; 95% confidence interval, 1.38-1.49). In twin pregnancies with gestational diabetes mellitus, compared with controls, there were increased risks of hypertensive disorders of pregnancy (relative risk, 1.69; 95% confidence interval, 1.51-1.90), cesarean delivery (relative risk, 1.10; 95% confidence interval, 1.06-1.13), large-for-gestational-age neonate (relative risk, 1.29; 95% confidence interval, 1.03-1.60), preterm birth (relative risk, 1.19; 95% confidence interval, 1.07-1.32), and admission to the neonatal intensive care unit (relative risk, 1.20; 95% confidence interval, 1.09-1.32) and reduced risks of small-for-gestational-age neonate (relative risk, 0.89; 95% confidence interval, 0.81-0.97) and neonatal death (relative risk, 0.50; 95% confidence interval, 0.39-0.65). When comparing relative risks in singleton vs twin pregnancies, there was sufficient evidence to suggest that twin pregnancies have a lower relative risk of cesarean delivery (P=.003), have sufficient adjustment for confounders, and have lower relative risks of admission to the neonatal intensive care unit (P=.005), stillbirths (P=.002), and neonatal death (P=.001) than singleton pregnancies.

CONCLUSION

In both singleton and twin pregnancies, gestational diabetes mellitus was associated with an increased risk of adverse maternal and perinatal outcomes. In twin pregnancies, gestational diabetes mellitus may have a milder effect on some adverse perinatal outcomes and may be associated with a lower risk of neonatal death.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis

OBJECTIVE

To investigate the association between gestational diabetes mellitus and adverse outcomes of pregnancy after adjustment for at least minimal confounding factors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Web of Science, PubMed, Medline, and Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 November 2021.

REVIEW METHODS

Cohort studies and control arms of trials reporting complications of pregnancy in women with gestational diabetes mellitus were eligible for inclusion. Based on the use of insulin, studies were divided into three subgroups: no insulin use (patients never used insulin during the course of the disease), insulin use (different proportions of patients were treated with insulin), and insulin use not reported. Subgroup analyses were performed based on the status of the country (developed or developing), quality of the study, diagnostic criteria, and screening method. Meta-regression models were applied based on the proportion of patients who had received insulin.

RESULTS

156 studies with 7 506 061 pregnancies were included, and 50 (32.1%) showed a low or medium risk of bias. In studies with no insulin use, when adjusted for confounders, women with gestational diabetes mellitus had increased odds of caesarean section (odds ratio 1.16, 95% confidence interval 1.03 to 1.32), preterm delivery (1.51, 1.26 to 1.80), low one minute Apgar score (1.43, 1.01 to 2.03), macrosomia (1.70, 1.23 to 2.36), and infant born large for gestational age (1.57, 1.25 to 1.97). In studies with insulin use, when adjusted for confounders, the odds of having an infant large for gestational age (odds ratio 1.61, 1.09 to 2.37), or with respiratory distress syndrome (1.57, 1.19 to 2.08) or neonatal jaundice (1.28, 1.02 to 1.62), or requiring admission to the neonatal intensive care unit (2.29, 1.59 to 3.31), were higher in women with gestational diabetes mellitus than in those without diabetes. No clear evidence was found for differences in the odds of instrumental delivery, shoulder dystocia, postpartum haemorrhage, stillbirth, neonatal death, low five minute Apgar score, low birth weight, and small for gestational age between women with and without gestational diabetes mellitus after adjusting for confounders. Country status, adjustment for body mass index, and screening methods significantly contributed to heterogeneity between studies for several adverse outcomes of pregnancy.

CONCLUSIONS

When adjusted for confounders, gestational diabetes mellitus was significantly associated with pregnancy complications. The findings contribute to a more comprehensive understanding of the adverse outcomes of pregnancy related to gestational diabetes mellitus. Future primary studies should routinely consider adjusting for a more complete set of prognostic factors.

REVIEW REGISTRATION

PROSPERO CRD42021265837.

The association between gestational diabetes and stillbirth: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Controversy exists over whether gestational diabetes increases the risk of stillbirth. The aim of this review was to examine the association between gestational diabetes and stillbirth.

METHODS

We performed searches of the published literature to May 2021. Study selection and data extraction were performed in duplicate by independent reviewers. Meta-analyses of summary measures were conducted using random-effect models for cohort and case-control studies separately. The study protocol was registered in PROSPERO (registration ID CRD42020166939).

RESULTS

From 9981 citations, 419 were identified for full-text review and 73 met inclusion criteria (n = 70,292,090). There was no significant association between gestational diabetes and stillbirth in cohort studies (pooled OR 1.04 [95% CI 0.90, 1.21]; I² 86.1%) or in case-control studies (pooled OR 1.57 [95% CI 0.83, 2.98]; I² 94.8%). Gestational diabetes was associated with lower odds of stillbirth among cohort studies presenting with an adjusted OR (pooled OR 0.78 [95% CI 0.68, 0.88]; I² 42.7%). Stratified analyses by stillbirth ≥28 weeks' gestation, studies published prior to 2013 and studies identified as low quality demonstrated a significantly higher odds of stillbirth in meta-regression (p = 0.016, 0.023 and 0.005, respectively). Egger's test for all included cohort studies (p = 0.018) suggests publication bias for the main meta-analysis.

CONCLUSIONS/INTERPRETATION

Given the substantial heterogeneity across studies, there are insufficient data to define the relationship between stillbirth and gestational diabetes adequately. In the main analyes, gestational diabetes was not associated with an increased risk of stillbirth. However, heterogeneity across studies means this finding should be interpreted cautiously.

Increasing trend in the prevalence of gestational diabetes mellitus in Taiwan

AIMS/INTRODUCTION

Maternal hyperglycemia leads to adverse pregnancy outcomes, and also subsequently affects both mothers and their offspring in later life. The prevalence of type 2 diabetes mellitus is increasing worldwide, and gestational diabetes mellitus (GDM) is also believed to be increasing. More precise nationwide and up-to-date data on GDM are required.

MATERIALS AND METHODS

A population-based retrospective cohort study was carried out with the Birth Certificate Application database and linked to the National Health Insurance Research Database to explore trends in the annual crude prevalence of GDM in all women who gave birth between 1 January 2004 and 31 December 2015 in Taiwan and their pregnancy outcomes. The registry is considered complete, reliable and accurate.

RESULTS

A total of 2,468,793 births from 2,430,307 pregnancies were reported between 1 January 2004 and 31 December 2015. Finally, 2,053,305 pregnancies were included for further analysis. The annual prevalence of GDM increased by 1.8-fold during the 12 years from 2004 to 2015, with a significant continuous increasing trend (from 7.6% to 13.4%, P < 0.001). The annual prevalence of GDM significantly increased in each age group (all trends P < 0.001), particularly for women with maternal ages of 31 years and older. Urbanization level, geographic risk factors and seasonal variations were also noted.

CONCLUSION

The annual prevalence of GDM increased by 1.8-fold in the 12-year period from 2004 to 2015 in Taiwan, with a significant continuous increasing trend (from 7.6% to 13.4%, P < 0.001).

Factors affecting the growth of children till the age of three years with overweight whose mothers have diabetes mellitus: A population-based cohort study

Background

The prevalence of diabetes mellitus (DM) during pregnancy and childhood obesity is increasing worldwide. Factors affecting the growth of children with overweight whose mothers had DM are complicated and inconclusive. Few longitudinal studies have focused on the growth of infants with macrosomia born to mothers with DM and the factors influencing their overweight. This study explored risk factors for childhood overweight/obesity (OWOB) among children of mothers with DM. Perinatal, maternal socio-demographic, infant care, and maternal body weight characteristics as well as child growth until age 3 years were analyzed using a longitudinal design.

Methods

In total, 24,200 pairs of mothers and their children from the Taiwan Birth Cohort Study were included. Combined Taiwan Children Growth Curve report classifications were analyzed for infant growth at birth and at 6, 12, 18, 24, and 36 months old (m/o). A multiple logistic regression analysis with different model settings was used to assess factors affecting the growth of high birth weight children of mothers with diabetic mellitus (HODM).

Results

Children in the HODM group had a higher average body weight than did those in the non-DM group at different age stages. Relative to the non-DM group, weight gain in the HODM group was slower before 18 m/o but faster from 18 to 36 m/o, particularly after 24 m/o. Maternal DM was a major risk factor for childhood OWOB (odds ratio [OR]: 3.25–3.95). After adjustment for related confounders, the OR was 2.19–3.17. Maternal overweight or obesity and higher gestational weight gain were greater risk factors for childhood OWOB at 3 years old after adjusted maternal DM and other selected confounders (OR: 1.45 and 1.23, respectively). Breastfeeding until 6 m/o was a protective factor against childhood OWOB (OR: 0.95). The HODM and non-DM groups did not differ significantly in perinatal, maternal socio-demographic, or infant care characteristics.

Conclusions

Maternal DM is a major factor of childhood OWOB. Maternal body weight before and after pregnancy affects childhood OWOB, and this effect increases with the child’s age.

Prevalence and risk factors of gestational diabetes mellitus in Asia: a systematic review and meta-analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is a of the major public health issues in Asia. The present study aimed to determine the prevalence of, and risk factors for GDM in Asia via a systematic review and meta-analysis.

METHODS

We systematically searched PubMed, Ovid, Scopus and ScienceDirect for observational studies in Asia from inception to August 2017. We selected cross sectional studies reporting the prevalence and risk factors for GDM. A random effects model was used to estimate the pooled prevalence of GDM and odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Eighty-four studies with STROBE score ≥ 14 were included in our analysis. The pooled prevalence of GDM in Asia was 11.5% (95% CI 10.9-12.1). There was considerable heterogeneity (I2 > 95%) in the prevalence of GDM in Asia, which is likely due to differences in diagnostic criteria, screening methods and study setting. Meta-analysis demonstrated that the risk factors of GDM include history of previous GDM (OR 8.42, 95% CI 5.35-13.23); macrosomia (OR 4.41, 95% CI 3.09-6.31); and congenital anomalies (OR 4.25, 95% CI 1.52-11.88). Other risk factors include a BMI ≥25 kg/m2 (OR 3.27, 95% CI 2.81-3.80); pregnancy-induced hypertension (OR 3.20, 95% CI 2.19-4.68); family history of diabetes (OR 2.77, 2.22-3.47); history of stillbirth (OR 2.39, 95% CI 1.68-3.40); polycystic ovary syndrome (OR 2.33, 95% CI1.72-3.17); history of abortion (OR 2.25, 95% CI 1.54-3.29); age ≥ 25 (OR 2.17, 95% CI 1.96-2.41); multiparity ≥2 (OR 1.37, 95% CI 1.24-1.52); and history of preterm delivery (OR 1.93, 95% CI 1.21-3.07).

CONCLUSION

We found a high prevalence of GDM among the Asian population. Asian women with common risk factors especially among those with history of previous GDM, congenital anomalies or macrosomia should receive additional attention from physician as high-risk cases for GDM in pregnancy.

TRIAL REGISTRATION

PROSPERO (2017: CRD42017070104 ).

Prevalence of Gestational Diabetes Mellitus in Eastern and Southeastern Asia: A Systematic Review and Meta-Analysis

AIM

To review the prevalence of gestational diabetes mellitus (GDM) in Eastern and Southeastern Asia.

METHODS

We systematically searched for observational studies on GDM prevalence from January 2000 to December 2016. Inclusion criteria were original English papers, with full texts published in peer-reviewed journals. The quality of included studies was evaluated using the guidelines of the National Health and Medical Research Council, Australia. Fixed effects and random effects models were used to estimate the summary prevalence of GDM and the corresponding 95% confidence intervals (CI).

RESULTS

A total of 4415 papers were screened, and 48 studies with 63 GDM prevalence observations were included in the final review. The pooled prevalence of GDM was 10.1% (95% CI: 6.5%-15.7%), despite substantial variations across nations. The prevalence of GDM in lower- or upper-middle income countries was about 64% higher than in their high-income counterparts. Moreover, the one-step screening method was twice more likely to be used in diagnosing GDM when compared to the two-step screening procedure.

CONCLUSIONS

The prevalence of GDM in Eastern and Southeastern Asia was high and varied among and within countries. There is a need for international uniformity in screening strategies and diagnostic criteria for GDM.

Carpenter-Coustan Compared With National Diabetes Data Group Criteria for Diagnosing Gestational Diabetes

OBJECTIVE

Use of Carpenter-Coustan compared with National Diabetes Data Group criteria increases the number of women diagnosed with gestational diabetes mellitus (GDM) by 30-50%, but whether treatment of this milder GDM reduces adverse outcomes is unknown. We explored the effects of the diagnostic criteria used on the benefits of GDM treatment.

METHODS

This was a secondary analysis of a randomized trial for treatment of mild GDM diagnosed using Carpenter-Coustan criteria. We evaluated the effect of treatment within two mutually exclusive diagnostic groups: 1) women who met the stricter National Diabetes Data Group as well as Carpenter-Coustan criteria (National Diabetes Data Group), and 2) those diagnosed by Carpenter-Coustan but not meeting National Diabetes Data Group criteria (Carpenter-Coustan only). Maternal outcomes examined were pregnancy-induced hypertension, shoulder dystocia, maternal weight gain, and cesarean delivery. Neonatal outcomes were large for gestational age, macrosomia (greater than 4,000 g), fat mass, small for gestational age, and a composite outcome of perinatal death, birth injury, hypoglycemia, hyperbilirubinemia, and hyperinsulinemia. Analysis of variance or the Breslow-Day test, as appropriate, was used to test for the interaction between diagnostic criteria and GDM treatment on the outcomes of interest.

RESULTS

Of 958 patients, 560 (58.5%) met National Diabetes Data Group criteria and 398 (41.5%) met Carpenter-Coustan only. Compared with untreated women, the direction of treatment effect did not differ by diagnostic criteria used and was consistent with the original trial. The P value for interaction between diagnostic criteria and treatment status was not significant for any outcome.

CONCLUSION

The overall beneficial treatment effect on pregnancy-induced hypertension, shoulder dystocia, cesarean delivery, and macrosomia was seen in patients diagnosed by the higher National Diabetes Data Group and by the lower thresholds of the Carpenter-Coustan criteria.

Diagnosis of gestational diabetes mellitus: comparison between National Diabetes Data Group and Carpenter– Coustan criteria

Background: A 100-g oral glucose tolerance test (OGTT) is commonly used to diagnose gestational diabetes mellitus (GDM). Carpenter-Coustan (CC) criteria, based on lower threshold plasma glucose values than the National Diabetes Data Group (NDDG) criteria, result in an apparently increased prevalence of GDM. However, the extent of the increase is not known, and effects on perinatal outcome are not clear.

Objective: To evaluate the increase in the prevalence of GDM if CC criteria are applied to OGTT results, we compared findings with NDDG criteria. Pregnancy outcomes between women without GDM and those with GDM diagnosed by NDDG and CC criteria were compared.

Methods: A total of 640 at-risk pregnant women were studied. They were either diagnosed as having GDM by initial testing (145 women), or repeat testing at 24−28 weeks of gestation (495 women). CC criteria were applied to the OGTT results and prevalence of GDM was re-evaluated.

Results: The apparent prevalence of GDM increased by 22.2% using CC criteria. The change was 27.6% at the initial test and 31.5% at repeat tests during 24−28 weeks of gestation. Infant birth weight in GDM diagnosed by either NDDG or CC criteria was significantly higher than in the negative OGTT group (P < 0.001). Rates of macrosomia were comparable. Neonatal hypoglycemia was 14.6% in the NDDG group, 8.2% in CC only group, and 4.6% in negative OGTT group (P < 0.001).

Conclusion: The CC criteria identify 22% more cases of GDM than NDDG criteria during initial and repeat tests.

Use of the National Diabetes Data Group and the Carpenter-Coustan criteria for assessing gestational diabetes mellitus and risk of adverse pregnancy outcome

Background

The influence of different diagnostic thresholds for gestational diabetes mellitus (GDM) on pregnancy outcomes is not fully understood. Degrees of glucose intolerance according to the Carpenter-Coustan (CC) criteria were less severe than the National Diabetes Data Group (NDDG) criteria for GDM. Recent studies have shown inconsistent results regarding the risk of adverse pregnancy outcomes between the NDDG and CC criteria. Therefore, the objective of this study was to investigate whether pregnant women who met only the CC criteria but not the NDDG criteria and those who met the NDDG criteria had increased risks of adverse pregnancy outcomes compared to a negative screening group.

Methods

A total of 11,486 Taiwanese pregnancies were enrolled in a retrospective cohort study. The study subjects were classified as follows: (1) negative screening group: women with negative 50-g glucose challenge test (GCT) results, (2) false-positive screening group: women with positive GCT results and negative 100-g OGTT results according to both CC and NDDG criteria, (3) CC-only-GDM group: women with positive GCT results plus GDM diagnosis meeting the CC but not the NDDG criteria, and (4) NDDG-GDM group: women diagnosed with GDM using the NDDG criteria. Multiple mixed effects logistic regression analysis was used to examine the relationships between the groups and pregnancy outcomes.

Results

There were 9002 (78.4 %), 1776 (15.5 %), 251 (2.2 %), and 457 (4.0 %) study pregnancies in the 4 groups. Compared with the negative screening group, the maternal outcomes were not different within groups except for gestational hypertension/preeclampsia. For neonatal outcomes, the CC-only-GDM group had significantly greater risks of macrosomia, low birth weight, and admission to a neonatal intensive care unit [adjusted odds ratio (aOR), (95 % confidence interval, CI): 2.73 (1.18–6.31), 1.64 (1.01–2.64), and 1.61 (1.05–2.46), respectively]. The NDDG-GDM group also showed significantly greater risks, and the false-positive screening group showed no differences from the negative screening group.

Conclusion

Women who met only the CC criteria and women who met NDDG criteria had significant increased risks of adverse neonatal outcomes. This evidence adds important information to the current debate about the diagnostic criteria for GDM regarding pregnancy outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1030-9) contains supplementary material, which is available to authorized users.

Pregnancy outcome in women with gestational diabetes mellitus according to the Carpenter-Coustan criteria in Thailand

AIM

To compare the pregnancy outcome of patients diagnosed with gestational diabetes mellitus (GDM) using the Carpenter-Coustan (CC) criteria with that of non-GDM pregnant women at Siriraj Hospital, Bangkok.

METHODS

A retrospective study was carried out by reviewing medical records of pregnant women who underwent 100-g oral glucose tolerance test (OGTT) for diagnosing GDM between January 2009 and December 2012 at Siriraj Hospital. Pregnant women were divided into three groups according to the 100-g OGTT result: group 1, pregnant women with normal OGTT on both CC and National Diabetes Data Group (NDDG) criteria; group 2, pregnant women with normal OGTT on NDDG criteria but GDM on CC criteria; and group 3, pregnant women with GDM on CC criteria after December 2012 and enrolled in glycemic control program. Maternal and perinatal outcomes were compared between the groups.

RESULTS

During the study period, the incidence of GDM increased 32.76% using the CC criteria. These women (group 2) had a higher risk of neonatal hypoglycemia (6.7% vs 0.6%; OR, 12.3; P < 0.0001), neonatal hyperbilirubinemia (13.7% vs 7.8%; OR, 1.9; P = 0.013) compared with group 1. Pregnant women in group 3 had a lower incidence of immediate post-partum hemorrhage from vaginal delivery than group 2 (0 vs 2.9%; P = 0.04) as well as lower rates of neonatal hypoglycemia and neonatal hyperbilirubinemia.

CONCLUSION

Use of CC criteria increases the prevalence of GDM, but managing these women according to the program for GDM can improve the adverse neonatal outcome.

Risk factors for gestational diabetes mellitus: ethnic disparities

OBJECTIVE

Gestational diabetes mellitus (GDM) increases the risk of poor maternal and infant health outcomes; therefore, the objective of this study was to compare the ethnic disparities and identify the risk factors for GDM.

DESIGN

We performed a cross-sectional analysis using patient records from a hospital located in the Puli area of Central Taiwan.

SETTING

A teaching hospital located in a rural mountainous area of Central Taiwan.

PARTICIPANTS

Between 2002 and 2012, the hospital admitted 154 patients (107 non-aborigines, 30 aborigines, and 17 non-Taiwanese) who exhibited glucose intolerance during their pregnancy.

MAIN OUTCOME MEASURES

GDM was confirmed using the oral-glucose-tolerance-test administered in dose of either 100 g or 75 g. The incidence and risk factors for GDM in the aboriginal and non-aboriginal women was compared.

RESULTS

We excluded the patients who had overt diabetes or were non-Taiwanese. Thus, 132 patients (28 aboriginal and 104 non-aboriginal women; mean age 30 years) were enrolled in the final study. A total of 51 patients (15 aboriginal, 36 non-aboriginal women) had GDM, which was more prevalent among the aboriginal mothers (53.6% versus 34.6%). The risk factors for GDM among the aboriginal women were persistent glycosuria and prior macrosomia.

CONCLUSION

The Taiwanese aboriginal women exhibited higher incidence of GDM; thus, we recommend that early screening and health education for pregnant aboriginal women be provided.

Diagnostic thresholds for gestational diabetes and their impact on pregnancy outcomes: a systematic review

AIMS

To assess different diagnostic thresholds for gestational diabetes on outcomes for mothers and their offspring in the absence of treatment for gestational diabetes. This information was used to inform a National Institutes of Health consensus conference on diagnosing gestational diabetes.

METHODS

We searched 15 electronic databases from 1995 to May 2012. Study selection was conducted independently by two reviewers. Randomized controlled trials or cohort studies were eligible if they involved women without known pre-existing diabetes mellitus and who did not undergo treatment for gestational diabetes. One reviewer extracted, and a second reviewer verified, data for accuracy. Two reviewers independently assessed methodological quality.

RESULTS

Thirty-eight studies were included. Three large, methodologically strong studies showed a continuous positive relationship between increasing glucose levels and the incidence of Caesarean section and macrosomia. When data were examined categorically (i.e. women meeting or not meeting specific diagnostic thresholds), women with gestational diabetes across all glucose criteria had significantly more Caesarean sections, shoulder dystocia, macrosomia (except for International Association of Diabetes in Pregnancy Study Groups' criteria) and large for gestational age. Higher glucose thresholds did not consistently demonstrate greater risk for all outcomes.

CONCLUSIONS

Higher glucose thresholds did not consistently demonstrate greater risk, possibly because studies did not compare mutually exclusive groups of women. A pragmatic approach for diagnosis of gestational diabetes using Hyperglycemia and Adverse Pregnancy Outcome Study odds ratio 2.0 thresholds warrants further consideration until additional analysis of the data comparing mutually exclusive groups of women is provided and large randomized controlled trials investigating different diagnostic and treatment thresholds are completed.

Incidence of adverse outcomes associated with gestational diabetes mellitus in low- and middle-income countries

BACKGROUND

The contribution of medical conditions such as diabetes mellitus to maternal and neonatal ill-health in low- and middle-income countries is not well documented.

OBJECTIVES

To ascertain the incidence of adverse outcomes associated with gestational diabetes mellitus (GDM) in these countries.

SEARCH STRATEGY

Electronic databases were searched between 1990 and 2011.

SELECTION CRITERIA

Observational, experimental, and quasi-experimental studies reporting adverse outcomes associated with GDM in mothers and their infants in low- and middle-income countries were included.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened, and full-text articles were independently assessed by at least 2 reviewers. Characteristics of studies were tabulated and quality assessment performed. Median and interquartile range (IQR) were computed for each adverse outcome.

MAIN RESULTS

25 articles were included from an initial 1282 citations. High median incidences of cesarean (43.8%; IQR, 34.9%-65.9%), neonatal jaundice (17.1%; IQR, 8.5%-22.9%), and macrosomia (17.0%; IQR, 8.3%-32.5%) were reported in women with GDM.

CONCLUSIONS

The high incidence of some complications of GDM is a concern and may indicate poorer care for women with GDM in low-resource settings. The wide IQRs found indicate uncertainty about the burden of GDM in these settings.

National Diabetes Data Group vs Carpenter-Coustan criteria to diagnose gestational diabetes

OBJECTIVE

The objective of the study was to compare perinatal outcomes among women diagnosed with gestational diabetes by the National Diabetes Data Group (NDDG) criteria with women meeting only Carpenter-Coustan criteria.

STUDY DESIGN

This was a 14 year retrospective cohort. Women who screened positive with 1 hour glucose load 140 mg/dL or greater underwent a diagnostic 3 hour oral glucose tolerance test. We report adjusted prevalence ratios (aPRs) of perinatal outcome risk.

RESULTS

Of the 4659 screen-positive women with diagnostic testing, 1082 (3.3%, of 33,179) met NDDG criteria; 1542 (4.6%, of 33,179), or 460 more, met Carpenter-Coustan criteria. These 460 untreated women had greater risk of preeclampsia than women diagnosed by NDDG criteria (aPR, 1.70; 95% confidence interval [CI], 1.23-2.35). They had a greater risk of cesarean delivery (aPR, 1.16; 95% CI, 1.04-1.30) and infants greater than 4000 g (aPR, 1.25; 95% CI, 1.01-1.56) than women not meeting either diagnostic criteria.

CONCLUSION

The 42.5% additional women diagnosed only by Carpenter-Coustan criteria are at greater risk for some adverse outcomes. Cost-effectiveness of a change remains to be determined.